Antihypertensive treatment: past, present and future.

THE PAST: Guidelines for pharmacological and non-pharmacological approaches to the treatment of hypertension were first published in 1977 and were subsequently revised in the 1980s. They were largely based on the approach known as 'stepped care', which suggests that antihypertensive treatment should be started with the initial use of a thiazide diuretic, followed by the addition of a second, third and fourth drug if no satisfactory therapeutic success is obtained. This approach was reviewed in the guidelines that followed, which indicated that pharmacological treatment should be started in a more liberal fashion by selecting the antihypertensive drug from among four rather than two classes (diuretics, beta-blockers, angiotensin converting enzyme inhibitors and calcium antagonists). THE PRESENT: The latest guidelines issued in 1993 by the World Health Organization/International Society of Hypertension and by the Joint National Committee contain innovative aspects on how to treat high blood pressure. They share common features, such as lifelong treatment of hypertension, attention to overall cardiovascular risk profile, initiation of treatment with lifestyle changes and subsequently with monotherapy, but they also have differences, such as goal blood pressure, initial blood pressure values to be treated and first-choice drug. For example, according to the World Health Organization/International Society of Hypertension guidelines first-choice drugs include five classes of drug, whereas the Joint National Committee guidelines advocate two classes of drug for first choice. THE FUTURE: It is likely that the 'stepped care' approach for hypertension treatment will continue to be employed in the future, although greater attention will be devoted to the need for combination drug treatment. Greater importance will be also given to the non-pharmacological antihypertensive approaches, as well as to baseline blood pressure values at which drug treatment should be started.